Provider Demographics
NPI:1790430692
Name:LIANIDIS, DESPINA (PA-C)
Entity Type:Individual
Prefix:
First Name:DESPINA
Middle Name:
Last Name:LIANIDIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 ROUTE 70 STE 100
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-9501
Mailing Address - Country:US
Mailing Address - Phone:609-267-9400
Mailing Address - Fax:
Practice Address - Street 1:131 ROUTE 70 STE 100
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NJ
Practice Address - Zip Code:08055-9501
Practice Address - Country:US
Practice Address - Phone:609-267-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-18
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MP00736200363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program